Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules 37299

List of Subjects in 33 CFR Part 110

Anchorage grounds.

Proposed Regulations

For reasons set out in the preamble,

the Coast Guard proposed to amend 33

CFR Part 110 as follows:

PART 110—[AMENDED]

1. The authority citation for Part 110

continues to read as follows:

Authority: 33 U.S.C. 471, 1221 through

1236, 2030, 2035, 2071; 49 CFR 1.46 and 33

CFR 1.05–1(g).

2. In § 110.155, add paragraph (c)(6) to

read as follows:

§ 110.155 Port of New York.

* * * * *

(c) * * *

(6) Anchorage No. 19–A. An area

located west of Hyde Park enclosed by

the coordinates staring at 41°48′35′′ N,

073°57′00′′ W; to 41°48′35′′ N,

073°56′44′′ W; to 41°47′32′′ N,

073°56′50′′ W; to 41°47′32′′ N,

073°57′10′′ W; thence back to 41°48′35′′

N, 073°57′00′′ W.

(i) No vessel may anchor in

Anchorage 19–A from December 16 to

the last day of February without

permission from the Captain of the Port,

New York

(ii) [Reserved]

* * * * *

Dated: June 3, 1998.

James D. Garrison,

Captain, U.S. Coast Guard, Acting

Commander, First Coast Guard District.

[FR Doc. 98–18396 Filed 7–9–98; 8:45 am]

BILLING CODE 4910–15–M

DEPARTMENT OF VETERANS

AFFAIRS

38 CFR Part 17

RIN 2900–AJI8

Enrollment—Provision of Hospital and

Outpatient Care to Veterans

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

SUMMARY: This document proposes to

amend VA’s medical regulations. The

Veterans’ Health Care Eligibility Reform

Act of 1996 mandates that VA

implement a national enrollment system

to manage the delivery of healthcare

services. Accordingly, the medical

regulations are proposed to be amended

to establish provisions consistent with

this mandate. Starting October 1, 1998,

most veterans must be enrolled in the

VA healthcare system as a condition of

receiving VA hospital and outpatient

care. Veterans would be allowed to

apply to be enrolled at any time. They

would be eligible to be enrolled based

on funding availability and their

priority status. In accordance with

statutory provisions, the proposed rule

also states that some categories of

veterans would be eligible for VA

hospital and outpatient care even if not

enrolled. This document further

proposes to establish a ‘‘medical

benefits package’’ setting forth, with

certain exceptions, the hospital and

outpatient care that would be provided

to enrolled veterans and certain other

veterans.

DATES: Comments must be received on

or before September 8, 1998.

ADDRESSES: Mail or hand-deliver

written comments to: Director, Office of

Regulations Management (02D),

Department of Veterans Affairs, 810

Vermont Ave., NW, Room 1154,

Washington, DC 20420. Comments

should indicate that they are submitted

in response to ‘‘RIN: 2900–AJ18.’’ All

written comments received will be

available for public inspection at the

above address in the Office of

Regulations Management, Room 1158,

between the hours of 8:00 a.m. and 4:30

p.m., Monday through Friday (except

holidays).

FOR FURTHER INFORMATION CONTACT:

Roscoe Butler, Health Administration

Service, (10C3), Veterans Health

Administration, Department of Veterans

Affairs, 810 Vermont Avenue, NW,

Washington, DC 20420, (202) 273–8302.

(This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: This

document proposes to amend VA’s

medical regulations at 38 CFR part 17.

Public Law 104–262, the Veterans’

Health Care Eligibility Reform Act of

1996, mandated that VA implement a

national enrollment system to manage

the delivery of healthcare services.

Accordingly, the medical regulations are

proposed to be amended to establish

provisions consistent with this mandate.

Starting October 1, 1998, most veterans

must be enrolled in the VA healthcare

system as a condition for receiving VA

hospital and outpatient care. They

would be allowed to apply to be

enrolled at any time. In accordance with

statutory provisions, the proposal also

states that some categories of veterans

would be eligible for VA hospital and

outpatient care even if not enrolled.

This document further proposes to

establish a ‘‘medical benefits package’’

setting forth, with certain exceptions,

the hospital and outpatient care that

would be provided to enrolled veterans

and certain other veterans.

National Enrollment System (Proposed

§ 17.36)

The proposed rule restates statutory

provisions by announcing that certain

veterans must be enrolled in the VA

healthcare system as a condition for

receiving VA hospital and outpatient

care. Also, consistent with the mandate

of Public Law 104–262, the proposed

rule contains a mechanism for

determining which categories of

veterans are eligible to be enrolled.

Moreover, the proposed rule includes

procedures for applying for enrollment,

continuation of enrollment, and

disenrollment; and provides for

notification to veterans of

determinations regarding their

enrollment status.

The proposed rule also contains

provisions for automatically enrolling

veterans who were enrolled prior to

October 1, 1998, in the VA healthcare

system under the trial VA voluntary

enrollment program that began on

October 1, 1997, if they are in a funded

priority category as explained below.

This would help avoid duplicate

decisionmaking and paperwork since

the trial VA voluntary enrollment

program used essentially the same

procedures for enrollment as those set

forth in the proposed rule.

Consistent with the statutory

mandate, the proposed rule provides

that the Secretary will determine which

categories of veterans are eligible to be

enrolled based on the following order of

priority:

(1) Veterans with a singular or

combined rating of 50 percent or greater

based on one or more service-connected

disabilities or unemployability.

(2) Veterans with a singular or

combined rating of 30 percent or 40

percent based on one or more serviceconnected disabilities.

(3) Veterans who are former prisoners

of war; veterans with a singular or

combined rating of 10 percent or 20

percent based on one or more serviceconnected disabilities; veterans who

were discharged or released from active

military service for a disability incurred

or aggravated in the line of duty;

veterans who receive disability

compensation under 38 U.S.C. 1151;

veterans whose entitlement to disability

compensation is suspended pursuant to

38 U.S.C. 1151, but only to the extent

that such veterans’ continuing eligibility

for hospital and outpatient care is

provided for in the judgment or

settlement described in 38 U.S.C. 1151;

veterans whose entitlement to disability

compensation is suspended because of

the receipt of military retired pay; and

veterans receiving compensation at the
37300 Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules

10 percent rating level based on

multiple noncompensable serviceconnected disabilities that clearly

interfere with normal employability

(4) Veterans who receive increased

pension based on their need for regular

aid and attendance or by reason of being

permanently housebound and other

veterans who otherwise would be

included in paragraphs (5) or (6) of this

section but who are determined to be

catastrophically disabled by the Chief of

Staff (or equivalent clinical official) at

the VA facility where they were

examined.

(5) Veterans not covered by

paragraphs (1) through (4) who are

determined to be unable to defray the

expenses of necessary care under 38

U.S.C. 1722(a).

(6) Veterans of the Mexican border

period or of World War I; veterans

solely seeking care for a disorder

associated with exposure to a toxic

substance or radiation or for a disorder

associated with service in the Southwest

Asia theater of operations during the

Gulf War, as provided in 38 U.S.C.

1710(e); and veterans with 0 percent

service-connected disabilities who are

nevertheless compensated, including

veterans receiving compensation for

inactive tuberculosis.

(7) Veterans who agree to pay to the

United States the applicable copayment

determined under 38 U.S.C. 1710(f) and

1710(g).

We also propose to establish the

following subcategories for priority

category 7:

(i) Noncompensable zero percent

service-connected veterans;

(ii) Catastrophically disabled veterans;

and

(iii) All other priority category 7

veterans.

In our view, this would provide an

equitable system for further prioritizing

the enrollment of priority category 7

veterans if VA were able to provide care

for only a portion of priority category 7

veterans.

Priority category 4 includes veterans

who are ‘‘catastrophically disabled.’’ We

have included a detailed definition of

this term in proposed § 17.36(e). We

believe this is consistent with the

Congressional intent.

In connection with the Secretary’s

determination regarding which

categories of veterans would be eligible

for hospital and outpatient care, the

proposed rule states that the Secretary

will publish in the notice section of the

Federal Register on or before October 1,

1998, a document announcing which

categories of veterans are eligible to be

enrolled. The proposed rule also states

that thereafter, it is anticipated that the

Secretary would publish in the notice

section of the Federal Register on or

before August 1 of each year the

determination of which categories of

veterans are eligible to be enrolled. It is

likely that the Secretary would have

sufficient information by August 1 of

each year to make an appropriate

determination. However, because of the

possibility that the initial determination

may require modification, the proposed

rule would allow the Secretary to revise

the determination by publication in the

notice section of the Federal Register as

necessary at any time. The proposed

rule also includes criteria for

determining which priority categories

will be eligible to be enrolled.

Veterans may appeal VA decisions

regarding enrollment and disenrollment

under the existing VA procedures,

which include the right to appeal to the

Board of Veterans’ Appeals and the

Court of Veterans Appeals.

Enrollment Not Required for Certain

Categories of Veterans (Proposed

§ 17.37)

Consistent with the provisions of

Public Law 104–262, the proposed rule

states that certain categories of veterans,

including veterans rated for serviceconnected disabilities at 50 percent or

greater, are not required to be enrolled

in the VA healthcare system as a

condition for receiving VA care.

Under Public Law 104–262, the list of

veterans not required to be enrolled

includes veterans ineligible to be

enrolled but who need care based on

‘‘compelling medical reasons.’’ Based on

our view of the statutory intent, the

proposed rule indicates that this covers

those cases when it is necessary to

complete a course of treatment started

when the veteran was enrolled in the

VA healthcare system.

Further, we note that we do not

believe that the authority for providing

hospital and outpatient care for

‘‘compelling medical reasons’’ was

intended to cover the provision of care

as a humanitarian service in emergency

cases. VA has separate and longstanding authority to provide care to

individuals such as non-enrolled

veterans in medical emergencies subject

to charges set by VA.

Medical Benefits Package (Proposed

§ 17.38)

This document also proposes to set

forth provisions explaining what care

would and would not be provided to

veterans enrolled in the VA healthcare

system. The Secretary has authority to

provide healthcare as determined to be

medically needed. In our view,

medically needed constitutes care that

is determined by appropriate healthcare

professionals to be needed to promote,

preserve, or restore the health of the

individual and to be in accord with

generally accepted standards of medical

practice. The care included in the

proposed ‘‘medical benefits package’’ is

intended to meet these criteria.

The proposed regulations also explain

that a veteran may receive certain types

of VA care not included in the ‘‘medical

benefits package’’ if authorized by

statute or other sections of 38 CFR (e.g.,

humanitarian emergency care for which

the individual will be billed,

compensation and pension

examinations, dental care, domiciliary

care, nursing home care, readjustment

counseling, care as part of a VAapproved research project, seeing-eye or

guide dogs, sexual trauma counseling

and treatment, special registry

examinations).

Technical Changes

The proposed rule also proposes to

make a number of technical

amendments to the medical regulations

for purposes of consistency.

OMB

This document has been reviewed by

the Office of Management and Budget

OMB under Executive Order 12866.

Paperwork Reduction Act of 1995

OMB has determined that proposed

38 CFR 17.36 would contain collections

of information under the Paperwork

Reduction Act of 1995 (44 U.S.C. 3501–

3520). Accordingly, under section

3507(d) of the Act, VA has submitted a

copy of this rulemaking action to OMB

for its review of the collections of

information.

OMB assigns a control number for

each collection of information it

approves. VA may not conduct or

sponsor, and a person is not required to

respond to, a collection of information

unless it displays a currently valid OMB

control number.

Comments on the proposed

collections of information should be

submitted to the Office of Management

and Budget, Attention: Desk Officer for

the Department of Veterans Affairs,

Office of Information and Regulatory

Affairs, Washington, DC 20503, with

copies mailed or hand-delivered to:

Director, Office of Regulations

Management (02D), Department of

Veterans Affairs, 810 Vermont Ave.,

NW, Room 1154, Washington, DC

20420. Comments should indicate that

they are submitted in response to ‘‘RIN

2900–AJ18.’’
Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules 37301

Title: Initial Application for Health

Benefits.

Summary of collection of information:

Under the provisions of proposed

§ 17.36(d)(1), a veteran who wishes to be

enrolled must apply by submitting a VA

Form 10–10EZ to a VA medical facility.

Veterans applying based on inclusion in

categories 1, 2, 3, 4, 6, and 7 do not need

to complete section II, but must

complete the rest of the form. Veterans

applying based on inclusion in priority

category 5 must complete the entire

form. VA Form 10–10EZ is set forth in

full at proposed § 17.36(f).

Description of the need for

information and proposed use of

information: This information would be

needed to determine whether a veteran

would be eligible to be enrolled in the

VA healthcare system and,

consequently, whether the veteran

would be eligible for VA hospital and

outpatient care.

Description of likely respondents:

Veterans wishing to be enrolled in the

VA healthcare system for the first time

in order to receive VA hospital and

outpatient care.

Estimated number of respondents:

1,000,000.

Estimated frequency of responses: 1.

Estimated total annual reporting and

recordkeeping burden: 333,333 hours.

Estimated annual burden per

collection: 20 minutes.

Title: Yearly Re-application for Health

Benefits.

Summary of collection of information:

Under the provisions of proposed

§ 17.36(d)(4)(iii), veterans enrolled

based on inclusion in priority category

5 would be mailed a Form 10–10EZ on

a yearly basis. They would be requested

to complete the form and return the

form to the address on the return

envelope. VA Form 10–10EZ is set forth

in full at proposed § 17.36(f).

Description of the need for

information and proposed use of

information: This information would be

needed to determine whether a veteran

would be eligible to continue to be

enrolled in the VA healthcare system,

and, consequently, whether the veteran

would be eligible to continue to receive

VA hospital and outpatient care.

Description of likely respondents:

Veterans in priority category 5 wishing

to continue to be enrolled in the VA

healthcare system in order to receive VA

hospital and outpatient care.

Estimated number of respondents:

1,372,766.

Estimated frequency of responses: 1.

Estimated total annual reporting and

recordkeeping burden: 343,192 hours.

Estimated annual burden per

collection: 15 minutes.

Title: Voluntary disenrollment.

Summary of collection of information:

Under the provisions of proposed

§ 17.36(d)(4)(i), a veteran wishing to

disenroll and forgo VA hospital and

outpatient care would submit to a VA

medical center a signed document

stating that the veteran no longer wishes

to be enrolled.

Description of the need for

information and proposed use of

information: This information is needed

to determine the identity of those

veterans wishing to disenroll and forgo

VA hospital and outpatient care. This

will help VA determine how to allocate

available funding for hospital and

outpatient care.

Description of likely respondents:

Veterans no longer wishing to receive

VA hospital and outpatient care.

Estimated number of respondents:

100.

Estimated frequency of responses: 1.

Estimated total annual reporting and

recordkeeping burden: 8.3 hours.

Estimated annual burden per

collection: 5 minutes.

The Department considers comments

by the public on proposed collections of

information in—

• Evaluating whether the proposed

collections of information are necessary

for the proper performance of the

functions of the Department, including

whether the information will have

practical utility;

• Evaluating the accuracy of the

Department’s estimate of the burden of

the proposed collections of information,

including the validity of the

methodology and assumptions used;

• Enhancing the quality, usefulness,

and clarity of the information to be

collected; and

• Minimizing the burden of the

collections of information on those who

are to respond, including responses

through the use of appropriate

automated, electronic, mechanical, or

other technological collection

techniques or other forms of information

technology, e.g., permitting electronic

submission of responses.

OMB is required to make a decision

concerning the collections of

information contained in this proposed

rule between 30 and 60 days after

publication of this document in the

Federal Register. Therefore, a comment

to OMB is best assured of having its full

effect if OMB receives it within 30 days

of publication. This does not affect the

deadline for the public to comment on

the proposed rule.

Regulatory Flexibility Act

The Secretary hereby certifies that

this proposed rule will not have a

significant economic impact on a

substantial number of small entities as

they are defined in the Regulatory

Flexibility Act, 5 U.S.C. 601–612. This

proposed rule would affect only

individuals. Accordingly, pursuant to 5

U.S.C. 605(b), this proposed rule is

exempt from the initial and final

regulatory flexibility analysis

requirements of §§ 603 and 604.

The Catalog of Federal domestic

assistance numbers for the programs

affected by this rule are 64.005, 64.007,

64.008, 64,009, 64.010, 64.011, 64.012,

64.013, 64.014, 64.015, 64.016, 64.018,

64.019, 64.022, and 64.025.

List of Subjects in 38 CFR Part 17

Administrative practice and

procedure, Alcohol abuse, Alcoholism,

Claims, Day care, Dental health, Drug

abuse, Foreign relations, Government

contracts, Grant programs health, Grant

programs-veterans, Health care, Health

facilities, Health professions, Health

records, Homeless, Medical and dental

schools, Medical devices, Medical

research, Mental health programs,

Nursing homes, Philippines, Reporting

and record-keeping requirements,

Scholarships and fellowships, Travel

and transportation expenses, Veterans.

Approved: May 12, 1998.

Togo D. West, Jr.,

Secretary.

For the reasons set out in the

preamble, 38 CFR part 17 is proposed to

be amended as set forth below:

PART 17—MEDICAL

1. The authority citation for part 17

continues to read as follows:

Authority: 38 U.S.C. 501, 1721 unless

otherwise noted.

§ 17.34 [Amended]

12. The first sentence of § 17.34 is

amended by removing ‘‘When an

application’’ and adding, in its place,

‘‘Subject to the provisions of §§ 17.36

through 17.38, when an application’’.

2. An undesignated center heading

and § 17.36 are added to read as follows:

Enrollment Provisions and Medical

Benefits Package

§ 17.36 Enrollment—provision of hospital

and outpatient care to veterans.

(a) Enrollment requirement for

veterans. (1) Except as otherwise

provided in § 17.37, a veteran must be

enrolled in the VA healthcare system as

a condition for receiving VA hospital

and outpatient care.

Note to paragraph (a)(1): A veteran may

apply to be enrolled at any time. (See

§ 17.36(d)(1).)
37302 Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules

(2) Except as provided in paragraph

(a)(3) of this section, a veteran enrolled

under this section is eligible for VA

hospital and outpatient care as provided

in the ‘‘medical benefits package’’ set

forth in § 17.38.

(3) A veteran enrolled based on

having a disorder associated with

exposure to a toxic substance or

radiation, or having a disorder

associated with service in the Southwest

Asia theater of operations during the

Gulf War, as provided in 38 U.S.C.

1710(e), is eligible for VA hospital and

outpatient care provided in the

‘‘medical benefits package’’ set forth in

§ 17.38 for the disorder.

(b) Categories of veterans eligible to be

enrolled. The Secretary will determine

which categories of veterans are eligible

to be enrolled based on the following

order of priority:

(1) Veterans with a singular or

combined rating of 50 percent or greater

based on one or more service-connected

disabilities or unemployability.

(2) Veterans with a singular or

combined rating of 30 percent or 40

percent based on one or more serviceconnected disabilities.

(3) Veterans who are former prisoners

of war; veterans with a singular or

combined rating of 10 percent or 20

percent based on one or more serviceconnected disabilities; veterans who

were discharged or released from active

military service for a disability incurred

or aggravated in the line of duty;

veterans who receive disability

compensation under 38 U.S.C. 1151;

veterans whose entitlement to disability

compensation is suspended pursuant to

38 U.S.C. 1151, but only to the extent

that such veterans’ continuing eligibility

for hospital and outpatient care is

provided for in the judgment or

settlement described in 38 U.S.C. 1151;

veterans whose entitlement to disability

compensation is suspended because of

the receipt of military retired pay; and

veterans receiving compensation at the

10 percent rating level based on

multiple noncompensable serviceconnected disabilities that clearly

interfere with normal employability.

(4) Veterans who receive increased

pension based on their need for regular

aid and attendance or by reason of being

permanently housebound and other

veterans who otherwise would be

included in paragraphs (5) or (6) of this

section but who are determined to be

catastrophically disabled by the Chief of

Staff (or equivalent clinical official) at

the VA facility where they were

examined.

(5) Veterans not covered by

paragraphs (1) through (4) of this section

who are determined to be unable to

defray the expenses of necessary care

under 38 U.S.C. 1722(a).

(6) Veterans of the Mexican border

period or of World War I; veterans

solely seeking care for a disorder

associated with exposure to a toxic

substance or radiation or for a disorder

associated with service in the Southwest

Asia theater of operations during the

Gulf War, as provided in 38 U.S.C.

1710(e); and veterans with 0 percent

service-connected disabilities who are

nevertheless compensated, including

veterans receiving compensation for

inactive tuberculosis.

(7) Veterans who agree to pay to the

United States the applicable copayment

determined under 38 U.S.C. 1710(f) and

1710(g). This category is further

prioritized into the following

subcategories:

(i) Noncompensable zero percent

service-connected veterans;

(ii) Catastrophically disabled veterans;

and

(iii) All other priority category 7

veterans.

(c) Federal Register notification of

eligible enrollees. The Secretary will

publish in the notice section of the

Federal Register on or before October 1,

1998, a document announcing which

categories of veterans are eligible to be

enrolled. Thereafter, it is anticipated

that the Secretary will publish in the

notice section of the Federal Register on

or before August 1 of each year a

document announcing which categories

of veterans are eligible to be enrolled.

As necessary, the Secretary at any time

may revise the determination by

publication in the notice section of the

Federal Register. A Federal Register

document published under this

paragraph must specify the total amount

of appropriated funds and other revenue

projected to be available for VA hospital

and outpatient care for veterans eligible

to be enrolled, specify the average

amount of cost projected for a veteran in

each priority category, and specify the

projected utilization of VA hospital and

outpatient care by veterans eligible to be

enrolled for each priority category

(based on experience from past years).

The determination should include

consideration of relevant internal and

external factors, e.g., economic changes,

changes in medical practices. Consistent

with these criteria, the Secretary will

determine which categories of veterans

are eligible to be enrolled based on the

order of priority specified in paragraph

(b) of this section.

(d) Enrollment and disenrollment

process—(1) Application for enrollment.

A veteran may apply to be enrolled in

the VA healthcare system at any time.

A veteran who wishes to be enrolled

must apply by submitting a VA Form

10–10EZ to a VA medical facility.

Veterans applying based on inclusion in

priority categories 1, 2, 3, 4, 6, and 7 do

not need to complete section II, but

must complete the rest of the form.

Veterans applying based on inclusion in

priority category 5 must complete the

entire form. VA Form 10–10EZ is set

forth in paragraph (f) of this section and

is available from VA medical facilities.

Note to paragraph (d)(1): To remain

enrolled based on inclusion in priority

category 5, a veteran annually must return to

VA information on a VA Form 10–10EZ as

provided in paragraph (d)(4)(iii) of this

section and otherwise meet the requirements

for enrollment.

(2) Action on application. Upon

receipt of a completed VA Form 10–

10EZ, a VA network or facility director

will accept a veteran as an enrollee

upon determining that the veteran is in

a priority category eligible to be enrolled

as announced in the applicable Federal

Register notice. Upon determining that

a veteran is not in a priority category

eligible to be enrolled, the VA network

or facility director will inform the

applicant that the applicant is ineligible

to be enrolled.

(3) Automatic enrollment.

Notwithstanding other provisions of this

section, veterans who were notified by

VA letter that they were enrolled in the

VA healthcare system under the trial VA

enrollment program prior to October 1,

1998, automatically will be enrolled in

the VA healthcare system under this

section if determined by a VA network

or facility director that the veteran is in

a priority category eligible to be enrolled

as announced in the applicable Federal

Register notice. Upon determining that

a veteran is not in a priority category

eligible to be enrolled, the VA network

or facility director will inform the

veteran that the veteran is ineligible to

be enrolled.

(4) Disenrollment. A veteran enrolled

under paragraph (d)(2) or (d)(3) of this

section will be disenrolled only if:

(i) The veteran submits to a VA

medical center a signed document

stating that the veteran no longer wishes

to be enrolled;

(ii) A VA network or facility director

determines that the veteran is no longer

in a priority category eligible to be

enrolled, as announced in the

applicable Federal Register notice; or

(iii) A VA network or facility director

determines that the veteran has been

enrolled based on inclusion in priority

category 5; determines that the veteran

was sent by mail a VA Form 10–10EZ;

and determines that the veteran failed to

return the completed form to the

address on the return envelope within
Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules 37303

60 days from receipt of the form. VA

Form 10–10EZ is set forth in paragraph

(f) of this section.

(5) Notification of enrollment status.

Notice of a decision by a VA network or

facility director regarding enrollment

status will be provided to the affected

veteran by letter and will contain the

reasons for the decision. The decision

will be based on all information

available to the decisionmaker,

including the information contained in

VA Form 10–10EZ.

(e) Catastrophically disabled. For

purposes of this section,

catastrophically disabled means to have

a permanent severely disabling injury,

disorder, or disease that compromises

the ability to carry out the activities of

daily living to such a degree that the

individual requires personal or

mechanical assistance to leave home or

bed or requires constant supervision to

avoid physical harm to self or others.

This definition is met if an individual

has been found by the Chief of Staff (or

equivalent clinical official) at the VA

facility where the individual was

examined to have a condition specified

in paragraph (e)(1) of this section or to

meet one of the conditions specified in

paragraph (e)(2) of this section.

(1) Quadriplegia and quadriparesis

(ICD–9 Code 344.0x), paraplegia (ICD–9

Code 344.1), blindness (ICD–9 Code

369.4), unspecified hemiplegia (ICD–9

Code 342.90), persistent vegetative state

(ICD–9 Code 780.03), or a condition

resulting from two of the following

procedures (ICD–9 Code 84.x) provided

the two procedures were not on the

same limb:

(i) Amputation through hand

(procedure code 84.03);

(ii) Disarticulation of wrist (procedure

code 84.04);

(iii) Amputation through forearm

(procedure code 84.05);

(iv) Disarticulation of elbow

(procedure code 84.06);

(v) Amputation through humerus

(procedure code 84.07);

(vi) Shoulder disarticulation

(procedure code 84.08);

(vii) Forequarter amputation

(procedure code 84.09);

(viii) Lower limb amputation not

otherwise specified (procedure code

84.10);

(ix) Amputation of toe (only if

accompanied by V49.71 code for

amputated great toe) (procedure code

84.11);

(x) Amputation through foot

(procedure code 84.12);

(xi) Disarticulation of ankle

(procedure code 84.13);

(xii) Amputation through malleoli

(procedure code 84.14);

(xiii) Other amputation below knee

(procedure code 84.15);

(xiv) Disarticulation of knee

(procedure code 84.16);

(xv) Above knee amputation

(procedure code 84.17);

(xvi) Disarticulation of hip (procedure

code 84.18); and

(xvii) Hindquarter amputation

(procedure code 84.19).

(2)(i) Dependent in 4 or more

Activities of Daily Living (eating,

dressing, bathing, toileting, transferring,

incontinence of bowel and/or bladder),

with at least 4 of the dependencies

being permanent, using the Katz scale.

(ii) A score of 10 or lower using the

Folstein Mini-Mental State

Examination.

(iii) A score of 14 or higher on the

Activities of Daily Living Index using

Resource Utilization Group III.

(iv) A score of 2 or lower on at least

4 of the 13 motor items using the

Functional Independence Measure.

(v) A score of 30 or lower using the

Global Assessment of Functioning.

(f) VA Form 10–10EZ. [insert actual

photocopy of VA Form 10–10EZ]

BILLING CODE 8320–01–P
37304 Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules 37305

BILLING CODE 8320–01–C
37306 Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules

(Authority: 38 U.S.C. 101, 501, 1701, 1705,

1710, 1721, 1722)

3. A new § 17.37 is added to read as

follows:

§ 17.37 Enrollment not required—

provision of hospital and outpatient care to

veterans.

Even if not enrolled in the VA

healthcare system:

(a) A veteran rated for serviceconnected disabilities at 50 percent or

greater will receive VA hospital and

outpatient care provided for in the

‘‘medical benefits package’’ set forth in

§ 17.38.

(b) A veteran who has a serviceconnected disability will receive VA

hospital and outpatient care provided

for in the ‘‘medical benefits package’’ set

forth in § 17.38 for that serviceconnected disability.

(c) A veteran who was discharged or

released from active military service for

a disability incurred or aggravated in the

line of duty will receive VA hospital

and outpatient care provided for in the

‘‘medical benefits package’’ set forth in

§ 17.38 for that disability for the 12-

month period following discharge or

release.

(d) When there is a compelling

medical need to complete a course of

VA treatment started when the veteran

was enrolled in the VA healthcare

system, a veteran will receive that

treatment.

(e) Subject to the provisions of

§ 21.240, a veteran participating in VA’s

vocational rehabilitation program

described in §§ 21.1 through 21.430 will

receive VA hospital and outpatient care

provided for in the ‘‘medical benefits

package’’ set forth in § 17.38.

(f) A veteran may receive VA hospital

and outpatient care based on factors

other than veteran status (e.g., a veteran

who is a private-hospital patient and is

referred to VA for a diagnostic test by

that hospital under a sharing contract; a

veteran who is a VA employee and is

examined to determine physical or

mental fitness to perform official duties;

a Department of Defense retiree under a

sharing agreement).

(g) For care not provided within a

State, a veteran may receive VA hospital

and outpatient care provided for in the

‘‘medical benefits package’’ set forth in

§ 17.38 if authorized under the

provisions of 38 U.S.C. 1724 and 38 CFR

17.35.

(h) Commonwealth Army veterans

and new Philippine Scouts may receive

hospital and outpatient care provided

for in the ‘‘medical benefits package’’ set

forth in § 17.38 if authorized under the

provisions of 38 U.S.C. 1734 and 1735.

(i) A veteran may receive certain types

of VA hospital and outpatient care not

included in the ‘‘medical benefits

package’’ set forth in § 17.38 if

authorized by statute or other sections

of 38 CFR (e.g., humanitarian emergency

care for which the individual will be

billed, compensation and pension

examinations, dental care, domiciliary

care, nursing home care, readjustment

counseling, care as part of a VAapproved research project, seeing-eye or

guide dogs, sexual trauma counseling

and treatment, special registry

examinations).

(Authority: 38 U.S.C. 101, 501, 1701, 1705,

1710, 1721, 1722)

4. A new § 17.38 is added to read as

follows:

§ 17.38 Medical benefits package.

(a) Subject to paragraphs (b) and (c) of

this section, the following hospital and

outpatient care constitutes the ‘‘medical

benefits package’’ (basic care and

preventive care):

(1) Basic care.

(i) Outpatient medical, surgical, and

mental healthcare, including care for

substance abuse.

(ii) Inpatient hospital, medical,

surgical, and mental healthcare,

including care for substance abuse.

(iii) Prescription drugs, including

over-the-counter drugs and medical and

surgical supplies available under the VA

national formulary system.

(iv) Emergency care in VA facilities;

and emergency care in non-VA facilities

in accordance with sharing contracts or

if authorized by §§ 17.52(a)(3), 17.53,

17.54, 17.120–132.

(v) Bereavement counseling as

authorized in § 17.98.

(vi) Comprehensive rehabilitative

services other than vocational services

provided under 38 U.S.C. chapter 31.

(vii) Consultation, professional

counseling, training, and mental health

services for the members of the

immediate family or legal guardian of

the veteran or the individual in whose

household the veteran certifies an

intention to live, if needed to treat:

(A) The service-connected disability

of a veteran; or

(B) The nonservice-connected

disability of a veteran where these

services were first given during the

veteran’s hospitalization and continuing

them is essential to permit the veteran’s

release from inpatient care.

(viii) Durable medical equipment and

prosthetic and orthotic devices,

including eyeglasses and hearing aids as

authorized under § 17.149.

(ix) Home health services authorized

under 38 U.S.C. 1717 and 1720C.

(x) Reconstructive (plastic) surgery

required as a result of disease or trauma,

but not including cosmetic surgery that

is not medically necessary.

(xi) Respite, hospice, and palliative

care.

(xii) Payment of travel and travel

expenses for veterans eligible under

§ 17.143 if authorized by that section.

(2) Preventive care, as defined in 38

U.S.C. 1701(9), which includes:

(i) Periodic medical exams.

(ii) Health education, including

nutrition education.

(iii) Maintenance of drug-use profiles,

drug monitoring, and drug use

education.

(iv) Mental health and substance

abuse preventive services.

(v) Immunizations against infectious

disease.

(vi) Prevention of musculoskeletal

deformity or other gradually developing

disabilities of a metabolic or

degenerative nature.

(vii) Genetic counseling concerning

inheritance of genetically determined

diseases.

(viii) Routine vision testing and eyecare services.

(ix) Periodic reexamination of

members of high-risk groups for selected

diseases and for functional decline of

sensory organs, and the services to treat

these diseases and functional declines.

(b) Provision of the ‘‘medical benefits

package’’. Care referred to in the

‘‘medical benefits package’’ will be

provided to individuals only if it is

determined by appropriate healthcare

professionals that the care is needed to

promote, preserve, or restore the health

of the individual and is in accord with

generally accepted standards of medical

practice.

(1) Promote health. Care is deemed to

promote health if the care will enhance

the quality of life or daily functional

level of the veteran, identify a

predisposition for development of a

condition or early onset of disease

which can be partly or totally

ameliorated by monitoring or early

diagnosis and treatment, and prevent

future disease.

(2) Preserve health. Care is deemed to

preserve health if the care will maintain

the current quality of life or daily

functional level of the veteran, prevent

the progression of disease, cure disease,

or extend life span.

(3) Restoring health. Care is deemed

to restore health if the care will restore

the quality of life or daily functional

level that has been lost due to illness or

injury.

(c) In addition to the care specifically

excluded from the ‘‘medical benefits

package’’ under paragraphs (a) and (b) of
Federal Register / Vol. 63, No. 132 / Friday, July 10, 1998 / Proposed Rules 37307

this section, the ‘‘medical benefits

package’’ does not include the

following:

(1) Abortions and abortion

counseling.

(2) Drugs, biologicals, and medical

devices not approved by the Food and

Drug Administration unless the treating

medical facility is conducting formal

clinical trials under an Investigational

Device Exemption (IDE) or an

Investigational New Drug (IND)

application, or the drugs, biologicals, or

medical devices are prescribed under a

compassionate use exemption.

(3) Gender alterations.

(4) Hospital and outpatient care for a

veteran who is either a patient or inmate

in an institution of another government

agency if that agency has a duty to give

the care or services.

(5) Infertility services.

(6) Membership in spas and health

clubs.

(7) Pregnancy and delivery.

(8) Reproductive sterilization, unless

medically necessary.

(9) Surgery to reverse voluntary

sterilization.

(10) Surgical implantation of penile

prostheses.

(Authority: 38 U.S.C. 101, 501, 1701, 1705,

1710, 1721, 1722)

§ 17.43 [Amended]

5–6. In § 17.43, paragraph (a) is

removed and paragraphs (b) through (e)

are redesignated as paragraphs (a)

through (d), respectively.

§ 17.47 [Amended]

7. In § 17.47, paragraph (h) is

removed; paragraphs (i) through (l) are

redesignated as paragraphs (h) through

(k), respectively; and newly

redesignated paragraph (h) is amended

by removing ‘‘hospital or’’ and by

removing ‘‘or hospital care in a Federal

hospital under agreement,’’.

§ 17.93 [Amended]

8. In § 17.93, paragraph (a)(2) is

amended by removing ‘‘Medical

services’’ and adding, in its place,

‘‘Subject to the provisions of §§ 17.36

through 17.38, medical services’’.

§ 17.99 [Removed]

9. Section 17.99 is removed.

§ 17.100 [Amended]

10. In § 17.100, the third sentence is

amended by removing ‘‘a new

application is filed, and’’.

[FR Doc. 98–18302 Filed 7–9–98; 8:45 am]

BILLING CODE 8320–01–P

ENVIRONMENTAL PROTECTION

AGENCY

40 CFR Part 52

[OH 114–1b; FRL–6123–2]

Approval and Promulgation of

Maintenance Plan Revision; Ohio

AGENCY: Environmental Protection

Agency.

ACTION: Proposed rule.

SUMMARY: The United States

Environmental Protection Agency (EPA)

is proposing to approve a March 13,

1998, request from Ohio, for a State

Implementation Plan maintenance plan

revision for the Columbus ozone

maintenance area. The maintenance

plan revision establishes an out year of

2010 for the area’s emissions budget.

The maintenance plan revision also

allocates to the 2010 mobile source

emissions budget a portion of the area’s

safety margin. The 2010 mobile source

emissions budget will be used for

transportation conformity purposes. The

safety margin is the difference between

the attainment inventory level of the

total emissions and the projected levels

of the total emissions in the final year

of the maintenance plan.

In the final rules section of this

Federal Register, EPA is approving the

State’s requests as a direct final rule

without prior proposal because EPA

views this action as noncontroversial

and anticipates no adverse comments. A

detailed rationale for approving the

State’s request is set forth in the direct

final rule. The direct final rule will

become effective without further notice

unless the Agency receives relevant

adverse written comment on the rule.

Should the Agency receive such

comment, it will publish a notice

informing the public that the direct final

rule did not take effect and such public

comment received will be addressed in

a subsequent final rule based on this

proposed rule. If no adverse written

comments are received, the direct final

rule will take effect on the date stated

in that document and no further activity

will be taken on this proposed rule. EPA

does not plan to institute a second

comment period on this action. Any

parties interested in commenting on this

action should do so at this time.

DATES: Written comments on this

proposed action must be received by

August 10, 1998.

ADDRESSES: Written comments should

be sent to: J. Elmer Bortzer, Chief,

Regulation Development Section, Air

Programs Branch, (AR–18J), U.S.

Environmental Protection Agency,

Region 5, 77 West Jackson Boulevard,

Chicago, Illinois, 60604.

FOR FURTHER INFORMATION CONTACT:

Scott Hamilton, Environmental

Scientist, Regulation Development

Section, Air Programs Branch (AR–18J),

U.S. Environmental Protection Agency,

Region 5, 77 West Jackson Boulevard,

Chicago, Illinois 60604, (312) 353–4775.

SUPPLEMENTARY INFORMATION: For

additional information, see the Direct

Final document which is located in the

Rules section of this Federal Register.

Copies of the requests are available for

inspection at the following address:

(Please contact Scott Hamilton at (312)

353–4775 before visiting the Region 5

office.) USEPA Region 5, Air and

Radiation Division, 77 West Jackson

Boulevard, Chicago, Illinois 60604–

3590.

List of Subjects in 40 CFR Part 52

Environmental protection, Air

pollution control, Hydrocarbons,

Intergovernmental relations, Ozone,

Nitrogen oxides, Transportation

conformity.

Authority: 42 U.S.C. 7401 et seq.

Dated: July 1, 1998.

David A. Ullrich,

Acting Regional Administrator.

[FR Doc. 98–18421 Filed 7–9–98; 8:45 am]

BILLING CODE 6560–50–P

ENVIRONMENTAL PROTECTION

AGENCY

[OPP–300680; FRL–6016–1]

40 CFR Part 180

RIN 2070–AB18

Food and Food By-Products Used as a

Pesticide; Proposed Exemption From

the Requirement of a Tolerance

AGENCY: Environmental Protection

Agency (EPA).

ACTION: Proposed rule.

SUMMARY: EPA proposes to establish an

exemption from the requirement of a

tolerance for residues of any edible food

commodity (except for peanuts, tree

nuts, milk, soybean, eggs, fish,

crustacea, and wheat) used as a

pesticide, when applied in accordance

with good agricultural practices, in or

on all food commodities. Any edible

food commodity used as a pesticide

under this exemption must not be

‘‘adulterated food’’ as defined in FFDCA

section 402. 21 U.S.C. 342. The

exemption from the requirement of a

tolerance is being proposed by the

Agency on its own initiative, since the